Provider Demographics
NPI:1063784700
Name:BLAKE PAIN SOLUTIONS PC
Entity type:Organization
Organization Name:BLAKE PAIN SOLUTIONS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-894-0365
Mailing Address - Street 1:PO BOX 1600
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98668-1600
Mailing Address - Country:US
Mailing Address - Phone:360-696-5022
Mailing Address - Fax:360-696-5445
Practice Address - Street 1:2312 NE 129TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-3236
Practice Address - Country:US
Practice Address - Phone:360-696-5022
Practice Address - Fax:360-696-5445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60071790261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8537383Medicaid